Giant Eagle Dispenses Antidepressants Instead Of Fertility Drugs, Now Taking It Very Seriously

The words “Clomiphene” and “Clomipramine” might look similar, but if you work in a pharmacy, you should know that they stand for very different things. Clomiphene is the generic version of the fertility drug Clomid. Clomipramine is a tricyclic antidepressant. A woman in Pittsburgh says that the pharmacy at a Giant Eagle grocery store gave her the antidepressant when she was prescribed the fertility drug. She had a severe allergic reaction and ended up in the emergency room.

“I called Giant Eagle immediately and said ‘Something is wrong with this prescription,’ and they said ‘Give me your name,’ and they placed me on hold. And when they returned back on the phone they said ‘Ma’am, you’re right, we gave you the wrong medication,'” [the woman] said.

[She] said her mother rushed her to the emergency room where doctors gave her five additional medications to keep her from going into anaphylactic shock.

The grocery chain, of course, told a local news station that they are “taking the incident very seriously and [are] working to rectify the situation.”

It appears that the incorrect medication name appears on a pamphlet the customer received. Always carefully check the printed information with your prescriptions, which should include a list of possible side effects and counterindications, a description of what the medication is used for, and sometimes a physical description of what your pills should look like.

I’m pretty sure they would have been working on a resolution before the media stepped in once the issue was discovered. I’m not a pharmacist, but I’m sure something like this does not look good at all for their pharmacy.

Well, there is a solution that’s being used more and more widely with computerized systems, called tall man lettering. In cases like this, the unique letters of similar-looking drug names are capitalized to make the differences clearer. A common example pair is DOPAmine/DOBUTAmine (or it might be doPAmine/doBUTAmine, I don’t remember.)

Just watched the video in the article. clomiPRAMINE is spelled as such on the bulk package. Fire everyone in the pharmacy who handled the medication.

Also, did this pharmacy stock their shelves in alphabetical order or something? These two drugs have nothing to do with each other, and alphabetical order is useless because most patients know the brand name only, even if they’re taking the generic. I would think pharmacies are normally organized by pharmaceutical class or something? Alphabetical order makes these sorts of errors likely.

Really? That’s the answer? Fire everyone who was there. Did you stop to think for a moment that the doctors chicken scratch handwriting was illegible and they filled what they thought he wrote? Did they asked her at pick-up if she had any questions(as required by law)? Did she refuse? Theres alot here we don’t know so don’t jump the gun and say fire everyone.

Ones where carelessness can cause death or severe, permanent disability are not among those.

There are DOZENS of ways the pharmacy could have resolved this, starting with requesting an electronic transmission of the prescription, and ending with a call to the physician. “The writing was illegible” is complete BS – if the pharmacist legitimately can’t read the prescription, they have no business filling it until they’ve contacted the prescribing physician.

But what happens if 2 or more people look at the prescription and it looks like what they filled out, and they were not confused. Who is to blame then? If you make a goose look like a swan, and you blame the other people when they said it looks like a swan , who is at fault? It should be the person doing the writing. hopefully they still have that prescription paper. If they take that same paper and 90% of the pharmacists that look at it think it is something (and here is the key) think it is that with little doubt of it being wrong, then it shouldn’t be the pharmacists fault..

I’m sure any pharmacist was working on a solution to the problem before the media was involved. It is possible the pharmacist told her to go to the ER after digging for more info on what was happening after she took the medication.

Tallman lettering is used on most generic drug bottles. Unfortunately, this safety net was overlooked. The technician/pharmacist who filled it should have checked the NDC (National Drug Code). However, if the prescription was written to where the pharmacist mistook Clomiphene for Clomipramine, then checking the NDC wouldn’t have mattered.

Yes, drug are sorted into alphabetical order in a pharmacy. Alphabetical Order is useless? Technicians wouldn’t be able to find any drug if they weren’t in alphabetical order. Every pharmacy I have ever worked in stocks drugs in alphabetical order.

Is this true for inpatient pharmacies too? I always thought the computer system treated it like other inventory software – this drug should be on aisle 5, shelf 2 (so that if there are multiple generics that the pharmacy can use, and they’re using the marketing name for any sort of organization, the same chemical drugs can be nearer to each other).

I don’t know a ton about the pharmacy side of things so I’ll defer to you.

I also just found out tall man is (mostly) voluntary, apparently. What’s up with that?

Yeah, these things happen unfortunately…no system is 100%. I wonder if it was indeed chicken scratch…it makes the most sense since the final check with the pharmacist brings up the typed label side-by-side with a scan of the written script on the computer system.

But even then, if there could be any reason to question the legibility, we’d usually call the prescriber to verify.

I am a Pharmacy Tech student. Pharmacists are supposed to check and double check that prescriptions are accurately dispensed. This is why they spend 4 or more years in school for.

However, I have seen written prescriptions from many doctors and even today doctors are writing illegible prescriptions. Their handwriting is terrible and the instructions are often abbreviated and very unclear. If there are any questions about a prescription, the Pharmacist should call the Doctor and verify the prescription. However, there are hundreds of illegible prescriptions in a single day.

A professional and responsible pharmacist should have caught this error while doing a double check. Clearly this Pharmacist made an error and should be disciplined for it. This was clearly the fault of the pharmacist who filled this prescription. An error like this should be extremely rare. This is an outrage to all of the responsible and trained Pharmacists and Pharmacy Technicians in this country. This gives everyone in the Pharmacy profession a bad name when it was clearly just one negligent individual.

If I were filling this prescription I would have called the doctor if the drug name was unclear. Also as a Pharmacy Technician, the prescription must be double checked by the pharmacist. So it is not just checked by me, but by another person.

Procedures must not have been followed, and this error was the fault of the Pharmacist and anyone else who might have counted the pills or anything else related to it.

Millions of prescriptions are responsibly filled each year. This clearly was a very extreme and unfortunate case.

Let’s keep it simple and use a 42 digit alpha-numeric tag,
as the pamphlet they’re currently using is ineffective…

More seriously though, as much as the situation is a terrible incident,
Pharmacists are human and mistakes happen.
Likewise, people should read the pamphlet’s attached to their prescriptions.
Heaven forbid you know what the drugs you’re putting into your body does.

Yay you!!! First comment that defends the corporation and finds fault with the OP.

Mistakes should not happen in pharmacies. There should be procedures in place to make sure that doesn’t happen, and the procedures should be followed 100% of the time.

As far as the consumer not reading the pamphlet, perhaps she already knew everything she needed to know about the drug she was prescribed. A consumer should not have to read the pamphlet to find out that the medicine is not the one she was prescribed.

Pharmacists receive a great deal of education and make a s***load of money. I agree that it’s not too much to ask to make sure they do their job correctly. Unlike my peon job where a mistake on my part might annoy someone, a mistake they make can KILL someone.

Sure I have – but there are procedures in place – double checking, testing, verifying, that happen before my product reaches the customer.

Pharmacies should have proper procedures in place to make sure that mistakes don’t make it all the way to the customer. Dispensing the right drug in the right amount should not be that hard to do correctly 100% of the time.

Nothing can be done with a 100% success rate. Nothing. This is a rarity, a statistical outlier, and is both predictable and acceptable given the millions of prescriptions filled by millions of people every day.

Dispensing the wrong drug, or the wrong strength of the right drug, can be extremely dangerous.

And it happens too often.

Just read the comments and you’ll see it’s happens more often than what I would define as rarely.

And I hadn’t yet even posted my story of this happening to me when I was in the Air Force and pregnant with my son and was prescribed something (can’t remember what, it’s been a long time ago) and was given Valium instead. The bottle said the correct drug name and the correct dosage, but after taking one pill, just before driving home from the AF hospital pharmacy, I became dizzy. I had to stop and use a pay phone to call my husband to come get me. The AF pharmacy acknowleged that the wrong drug was dispensed and gave me the correct one. My son was born with no problems, but I wonder what would’ve happened if I was supposed to take several pills at once, or if I kept taking them until the bottle was empty.

My work is checked by others before it goes forward. Then it’s tested by still other people before going forward from there. And nobody’s health or life is at stake. Surely we can expect Pharmacies to use double checking, or something similar?

Maybe I’m cynical about this because I’ve lost any faith I might have had in people working in the retail industry.

And before some pharmacist jumps down my throat, keep in mind that I’m a smart guy. I know pharmacists have years of intensive training and education. It just seems to me that every time I go to the pharmacist, the entire procedure consists of them reading my scrip, using a computer to crosscheck interactions, and then filling a small bottle from a larger bottle. It’s not like they’re back there with Bunsen burners and a mortar and pestle.

So, yeah, you’re right, there shouldn’t be any errors, but since they spend their entire day squinting at crooked handwriting and then transferring premarked pills from one container to the next, I’ve come to expect the occasional screwup.

Medco has a problem with it. After having an allergic reaction to a generic of a drug I take my doctor when he wrote the prescription wrote do not substitute, medically necessary all over it and what did they do? Send me the generic anyway, which I saw on the website after it was shipped out and called to complain and get the RIGHT one since I was leaving the country shortly. To add insult to injury, they put a letter in saying that my doctor had okayed the switch to save me money. (For the record my Dr. NEVER okayed it and Medco never contacted them) So yeah I check everything. In other sane countries each generic actually has a brand name so if you find a generic that works for you, you can be sure to stay with it every time.

Pharmacies dispense millions upon millions of prescriptions daily – I’d say events like this are very rare considering the chance of mistakes. Until the pharmacy is 100% automated, these things will happen. Doesn’t make it right, and doesn’t make me a “defender of the corporations” – it just means I’m realistic about the process. Pharmacists have a responsibility to dispense the right meds, and the customer has a responsibility to check what they received.

The part that really annoys me is that the drug companies who patent the drugs get to choose the generic names, so they purposely choose names that are difficult to pronounce and remember, using letter combinations that don’t routinely occur in English (hello, rofecoxib?)
The idea is that if doctors and patients can only remember the brand name, they’re more likely to prescribe/request the name brand once a generic becomes available.
Hence, even more confusion, that can even be dangerous as this situation indicates.

One time when I was in a hospital — c. 15 years ago — I was given an incorrect medication. Fortunately in my case, there was no harm done; I wasn’t allergic to the incorrect pill (as the person was in this article); they discovered the mistake fairly quickly; and I was able to get the correct pill in a couple hours, so I wasn’t set back.

Even so, this incident made me vigilant about taking pills. In a clinical setting I always ask what something is; at the pharmacy I check everything carefully. If I get any pills that look different, I always ask about it (and in every case it’s because they changed suppliers for generics, it was the same drug).

MY pharmacies ALWAYS explain what the drug is and asks if I know how to use it. Also if there is a manufacturer change, they will ALWAYS bring that to my attention . Seems some usual steps were missed here??

These stories make me very nervous… My daughter is on a new medication every other month, or they are changing doses, substituting this seizure med for that one… you get the picture. I look everything over on her med sheets and keep the pile of them stashed away for the side effects and I know what her regular pills look like, but I probably would never be able to tell the difference between her liquid meds.

I’ve been there; my wife suffered an onset of adult epilepsy while we were in college, and it lasted for a couple of years. The process of finding and stabilizing the right medication was one of the most stressful experiences I’ve ever been through – it felt like such a ridiculous trial and error process. Dealing with constant and unexpected reactions to incorrect dosages was a nightmare. I can’t even imagine how hard it must be with a child, my heart goes out to you. Eventually, we found the right balance and life was better; they never really identified the root cause (the most honest answer we got was they just didn’t know, but that adult brains go through a final stage of growth in these years that might have somehow been an influence). Several years later, it stopped happening alltogether. I hope you guys have the same relief.

The pamphlets I get with my prescriptions describe the medication. The bottle has a spot on it too. It’ll say “small, pink, marked B33″ in the pamphlet, and “small, pink” on the bottle. So, while you shouldn’t have to, you can check that out. You say that you wouldn’t know if there was a mistake, but this is an added layer of safety/comfort.

If this isn’t printed on the info the pharmacy gives you, there are a few reliable web locations that give the same info, often with pictures. (Also helpful for when you find a random pill on the floorboard of your car and want to know what the heck it is.)

I know you shouldn’t have to, I know there shouldn’t be mistakes, but I always check, and if I had kids, I’d always, always check.

Sorry you’re going through so much getting her the right meds. Hope it settles down soon for you all.

Lol, happened to me once. The medication that I take regularly has a similar name to a medication for toenail fungus. The pills look TOTALLY different. They put the right information on the packet, it’s just the bottle said, “diamond shaped pill” and the medication inside was white ovals. I called the pharmacy back and they were very embarrassed, fixed it immediately.

I guess someone just spaced out. Amusingly enough, about a week later I DID get toenail fungus and had to go back and get that pill again!

Someone please tell me why the filling out of prescriptions isn’t automated yet. Most of my prescriptions nowadays aren’t handwritten, they’re run off on a laser printer. Throw in a 2D bar code, a machine that will automatically count pills and label the pill bottle, and most pharmacy work becomes idiotproof. The bottles pills are shipped in are more and more often including RFID tags, so you can’t even screw up on that end.

A human still has to put the right pills in the right bin that your hypothetical automated system retrieves them from.

There is no way to remove the human element from the process. Which is to say, that there is no way to make the process 100% foolproof. These mistakes will happen occasionally. The ultimate responsibility lies with the consumer to make sure they are taking the correct medication. If that means asking your doctor to write the prescription legibly, repeating the prescription to the pharmacist 3 times, and inspecting the literature and pills, then so be it.

I’m not making excuses for Giant Eagle. They should find out if this was caused by some systemic problem or if the employee involved has a history of making these kinds of mistakes. But humans, no matter how vigilant, will always have the capacity for mistakes.

Well, that’s why I mentioned the RFID. You’re right, nothing is completely free of human error. My first instinct it to look to technology to fix things. Perhaps not always the best response.

I tend to get paranoid about getting the right pills. Every time my pharmacy switches supplies, I end up with different looking pills for the same medication. Once, and only once, did I find the wrong pills in my properly labeled bottle. 200 mg pills instead of 100 mg, the different color was a dead giveaway. The internet makes it so much easier to verify pills by appearance now.

Nice link. However, most of these are software problems that could be corrected by software, but the software produces aren’t forced to fix them because the pharmacists can work around them. A robot can’t work around them, so they’ll be forced to fix the problems.

After doing some research, I’m having a very hard time finding any reference to your ‘millions of dollars’ claim. To be fair though, I’ve had no luck on prices for prescription filling machines. Pill counters run about 5k, and automated dispensing machines run about 55k-60k. What I have seen are machines pitched for pharmacies that do 100-200 scrips/day, as well as pharmacies that do larger volumes.

All the machines I’ve seen work with containers shipped directly from the supplier. Heck, I even recognized the containers from my non-automated pharmacy. Getting the wrong pills out of a system like that would either require a wrong prescription in the first place, or packaging errors at the manufacturer’s level.

Here in Michigan most prescriptions are still hand-written or called in to the pharmacy by telephone. Sometimes those handwritten prescriptions are hard to read, I don’t know how my pharmacist reads them (I haven’t had any med mistakes in years, so he must be able to read the doc’s messy handwriting).

Reminds me of when I went to pick up my wife’s prenatal vitamins, 100 of them. The bottle (of 100) clearly said do NOT use if seal is broken. I checked right there and the seal was gone. So I told them about it and they said it was “OK because we count out the correct amount from open bottles.”

I said it’s supposed to be 100, the bottle HOLDS 100, give me an unopened bottle. We went round n round for a while, eventually I left with my unopened bottle, a bit more confident that they were the correct pills.

I know if it had been regular prescription meds they would be from some ‘open bottle’, but don’t hand me something unsealed that says it must be sealed!

Kudos to you. Whenever I get open stock meds I feel like I need count out every pill at the counter to make sure I’ve been given the right amount, even if I won’t take all of them. I just don’t want to pay for an amount I haven’t received, and if you don’t correct it right then and there, the pharmacy is less inclined to believe you or worse, flag you for potential misuse.

One time I went to the pharmacy to pick up next month’s meds a little earlier than the established fill date because I would run out before returning from a vacation, and the pharmacy told me that it would have to ask the insurance company. The pharmacist typed in all my info and the insurance company automated system denied my additional dose because, according to the schedule, I was still a week’s worth of medication away from needing the next month’s dose. I made the pharmacy call the insurance company to explain to them why I needed the extra allergy meds and then the pharmacy let me have them.

The pharmacy did not let you have them. The insurance company did. They are very stingy about their money.

Secondly, please remember that when we call an insurance company for you, we are doing you a favor. It is not our job to fix your insurance. Our job is to get you your medication safely and effectively. However, most pharmacies go above and beyond to help patients with insurance problems.

Technically in this situation, you should have called the insurance company to resolve the problem.

Fubish says: I don't know anything about it, but it seems to me...says:

Nuts to that. If you want my money you WILL do me a favor and help get my medication or I will go to a more customer friendly pharmacy. You make it sound like your pharmacy is just a bureauocracy and does nothing but push items across the counter and take money in return just like any other retail dump selling clothing or golf balls. What ever happened to the professional pharmacist or technician who actually was glad to assist customers? I guess they are few and far between. Luckily, my local pharmacist actually CARES about his clients.

There was nothing to “fix” with my insurance – it was a standing order for a refill every month and it had been like this for years.

The insurance company system automatically flags for things like this – all you have to do is call to explain the situation, but I wanted my pharmacy to call because they are the gatekeepers of the medication and I was afraid that if I called the insurance company on my own time, then went back to the pharmacy, the pharmacy would have no proof that the insurance company authorized the early refill. I didn’t know whether the insurance company would fax a note, or add a note to my account, or anything. It was to ensure that someone would be able to vouch for me that I had received permission from my insurance company.

My local CVS is usually really good about this. One time I accidentally spilled half a bottle of one of my meds down the sink, and when I went back in for a refill it wasn’t ready yet because the insurance company said it was too soon. After asking if I was going on vacation or if there was some other reason, they offered to call the insurance company for me to get it refilled right away. In fact, I think they just gave me the refill right then and called the insurance co. afterwards. Very nice of them.

(They’re also regularly willing to give someone 2-3 pills of a med if the person is out of them, and still waiting on a refill from their doctor or something. It WILL be subtracted out of the prescription they eventually give you [ie they’ll fill it for 27 pills instead of 30] but it can be REALLY useful in an emergency.)

Pharmacies (various) I work with regularly give me medications in their original shipping bottles. Medications are dispensed from these bottles frequently in non-unit numbers, so I get half bottles sometimes. It makes sense as the volumes of pills I get are large and it just makes sense to give me the original bottles. Any time you get pills in an orange RX bottle, you can bet the original packaging was opened long before you got there.

You can’t even be sure if your pills all of a sudden look markedly different. Pharmacies switch their generic manufacturers all the time and each company’s pill looks different for the same drug. Also, generics have more leniency with their exact dosages.

Um, I’m not sure exactly what you Consumerist commandos expect the chain to do? People and companies make mistakes. Should they have done a precog style future reading of the situation to head off the mistake before it happened ala Minority report. You have to consider that Giant Eagle is looking into how the mistake happened and how to keep it form happening again. Isn’t that what we should expect from a decent company?

I expect them to have procedures in place to make sure this doesn’t happen. The easiest procedure would be to double check and triple check and then quadruple check, if necessary, that the correct drug is dispensed. This is not a little problem like Amazon shipping the wrong book.

Having worked in a pharmacy, i can tell you all that the wrong mix of people (an inexperienced pharm tech, a not-so-attentive pharmacist), this can easily happen. ALWAYS check your meds and the literature that comes with them. I am sure having a regular pharmacist qualms these fears, but when it’s something new and important- check.

The worst that ever happened to us was counting wrong, but even that can be a big deal. There are procedures that must be done when the wrong medicine is given out, people to call, reporting, etc. This is pretty serious. People die when things like this happen.

Having a regular pharmacist is a great help for things like this. My pharmacist knows what my conditions are, so if I were to get something way off the wall, he’d check it an extra time, then probably make sure to call my attention to it just in case.

It’s worth waiting a little longer, sometimes even paying a little more. At least to me.

Every time I get my prescription from the pharmacy, this is why I check. And of all the times I checked, ONCE it happened that they gave me the wrong pill than what was on the bottle. It was the right medication, but a different manufacturer, so the shape/color/imprint was wrong.

ALWAYS CHECK PEOPLE. Just because they screw up doesn’t mean you aren’t at fault. Even in the McDonalds coffee case, the victim was held partially responsible.

That’s what the Dr’s office did to me two days ago. Kid sick, feverish, miserable, howling about ear pain for two days. Go to doc, asked me where I wanted the scrip sent, I told them. Get prescription e-scribed to pharmacy. Drove to pharmacy. Had sick, feverish, miserable kid with me. Repeated checks over 45 minutes, hasn’t showed up at the pharmacy. Call Dr’s office. “Oh, it’s been sent.” Repeated checks over 30 minutes– not here. No help or suggestion of help from the drop-off clerk, just a “Hasn’t shown up. NEXT!” I’m on my own. DRIVE back to Dr’s office, they sent it to the WRONG pharmacy. Back to pharmacy. Finally showed up. “Ready in about 20 minutes.” Check back in 25. “Not ready yet, check back in 20 minutes.” (We’re at about 2 hours now, with a kid sick and in tears, wanting to go home.) I ask if they can move it up a bit, because we’ve already been there 2 hours, and the first-of-the-month prescription people line was getting REALLY LONG. Okay. A few minutes later,”Did you know this will cost $60?” “WHAT? Last time I bought this medication, it cost less than $10! WHAT IS GOING ON?! DON’T FILL IT! I’ll find out what is going on tomorrow!” By now, I was really getting upset. They checked it out, and the scrip sent to the wrong pharmacy was never CANCELED, and/or were never contacted about the issue, so the insurance was covering that one, and not the one I was actually receiving. Pharmacist called the other store to get that one canceled. 2-1/2 hours later, I finally got my scrip and was finally able to take my sick kid home and to bed. Walking out to the parking lot, I burst into tears just from the stress of the whole situation.
I squarely blame the Dr’s office, but I also blame the pharmacy for not, at the very least, throwing me a bone in the beginning and trying to help me out a little bit. I’m not going back to the unhelpful pharmacy, and I think I’m switching Dr’s offices, too. I’ll let them know why.
Sorry for the rambling/venting, but the wound of this event is still fresh and bleeding. If I had a paper scrip in my hand, this WOULD NOT HAVE HAPPENED.

I can certainly understand their situation. I just recently found out that I had been taking the maximum dose of a particular medication that I was never supposed to have had in the first place. For months I have been taking this with refills being given to me by the doc. I went to him for my follow-up and asked him if I could have a cheaper drug. He asked what drug and his response was, “Ask the prescribing doctor.” He WAS the prescribing doctor and had no clue. After he started looking through my records, he said I should have never been on it in the first place and he has no idea how it got prescribed. That was odd considering his office gave me the prescription in the first place.

I understand people make mistakes, but some mistakes can kill. No wonder health costs are so high. Malpractice insurance premiums sometimes make up the majority of a doctor’s salary.

I hope that the woman gets compensation for this. One reason that some drugs are Rx is so that they can be dispensed properly. I get my prescriptions from an outpatient pharmacy associated with a clinic/hospital. The pharmacists there are SO MUCH better than at a place like Walgreens. They always show you the drug and double check that it’s the correct drug.

Well, yeah, me too. And what I mean by that is that I hope Giant Eagle pays for all hospital bills (including any deductible she may have had), medically reasonable follow-up care attributable to the allergic reaction, lost wages during hospitalization, plus a REASONABLE cash kicker for bona fide pain and suffering, that is, objectively verifiable manifestations of physical distress caused by consuming the negligently supplied pills. To wit: nausea, diarrhea, vomiting, fever or inflammation, headache, dizziness, insomnia, cognitive impairment, etc. What I would absolutely loathe (in the absence of other facts unknown to me) would be a claim based on emotional anguish or the onset of a chronic or acute psychological impairment that only money can buy.

The pharmacy was plainly negligent here but, to its credit, came clean at the earliest opportunity and should not be mulcted with an outsized payout.

The OP may have checked the bottle before taking the medicine but made the same mistake the pharmacy did.

Always carefully check the printed information with your prescriptions, which should include a list of possible side effects and counterindications, a description of what the medication is used for, and sometimes a physical description of what your pills should look like.

I like to do this even with stuff I take regularly because I want to see if anything has changed.

A friend’s mom was given a drug for testicular cancer (which would have rendered her sterile if she hadn’t already gone through menopause) instead of an anti-inflammatory. The drug she was given even has warnings on the pharmacy’s instructions … under no circumstances give this drug to women or children.

Saw something similar happen on an episode of House. Since I don’t have an all-star “diagnostician” in my city, now I always ask the doctor what I’m supposed to be getting and I actually double-check that’s what I got.

Thanks, House. I also frequently diagnose myself with those rare diseases.

Check your pills. Always. I was on Coumadin–a blood thinner–and taking alternating doses. One time they mixed the pills up (or the labels). Luckily they were two different colors and I noticed the mistake before I downed four 4 mg pills, which could have killed me.

I called the pharmacy and they told me to bring them back and they would fix it. They were horrified because of what kind of medicine it was. They were very apologetic and gave me the right pills without charging me any extra.

I always check now before I leave the pharm, because people do make mistakes. If anyone raises an eyebrow, I tell that story and they understand immediately.

I received wrong pills from a pharmacy – they belonged to a gentleman that has a similar name to mine but address/gender/dob completely different. They also billed his insurance for them.

I took the pills back and even explained I was deadly allergic to them. They shrugged and giggled and said my name was so close to the other patient. Clearly it was MY fault! Then they made me wait 45 minutes to fill a correct rx.

Always check your meds closely. I dont know why more ppl don’t. Pharmacies can also legally sell you pills that will expire tomorrow – even if it is a six month supply. Rite-aid did that to me. I ask to see the original pill bottle now and write the “real” date on my bottle. Pharmacies all put one year from the date they fill it as the exp. date which clearly would rarely be correct. Also make sure the refills remaining are correct on your bottle – pharmacies will leave that at “zero” incorrectlya t times (and an addl office doctor visit will have to be paid for or an inconvience for both of you if nothing else).

I might sound a little fussy – but I started the date checking when I didnt have ins and was spending $900 on meds…$300 worth I had to throw out. Same on paying out of pocket for a doctor visit so I could get a new script written, although the refills had been on the original rx (but the pharmacy screwed up)

This EXACT drug mixup happened to my wife a few months ago, and landed her in the ER too. The pharmacy screwed up, giving her the antidepressant, but at the dosage level for the fertility drug. My wife wound up taking six times the normal starting dosage for the antidepressant, and it left her unable to walk or stand, and she had a very hard time thinking or moving as well. She was terrified and thought she had suffered a stroke but eventually made her way to a phone and called me at work. A co-worker and I raced home and took her to the ER. Long story short, she wound up being fine, eventually, as she was not allergic, but the drug has a pretty long half-life and it took several days for it to completely exit her system.

Our pharmacy “took it seriously” enough that the pharmacist “is no longer employed there”, and their liability insurance covered the medical bills. It’s somewhat inexcusable, in my opinion, for this to happen. Clomiphene is prescribed typically for a few days out of the month, and is labeled as such on the bottle. I never heard of anyone taking an antidepressant for only a week, that should trip a HUGE red flag to the person filling the prescription.

Same thing happened to my wife from the same chain of pharmacies but outside of Pittsburgh. She was prescribed a narcotic for pain management and the pharmacy gave her something with a similarly spelled name but drastically different application. Blaming the OP is easy as blaming the Pharmacy and the doctor. However, consider that if this is a refill or a maintenance prescription not every consumer is going to continually check all the paperwork and labeling when they pick up the meds. It becomes a repetitive action. And if you are older, you may not have the faculties or eyesight to clearly understand these things.

The only thing that would tip most people off is the difference in price. Generic drugs what they are, sometimes they change the manufacturer or even the design of the pill so that can be overlooked because you trust the pharmacist and the doctors. Unfortunately, my wife had already taken one before she noticed the mix up. She called the pharmacy back and the on staff senior pharmacist ensured her that sheâ€™d be OK but to be aware of any noticeable changes (allergic reaction).

I agree, there should be a more electronic way of doing things. The doctor should not write out the prescription anymore or at least write it on a PDA or mobile device that has OCR or some other recognition software which then prompts the doctor or PA to confirm their choice of meds. When the patient goes to the desk to settle up and what not, a print out from that PDA is handed to them as their prescription or that prescription is sent to the pharmacy electronically.

Both drugs come in a 50mg form, which is what might have also contributed to the confusion. If one were typically 5mg and the other were 350mg, then maybe alarm bells would have gone off. Not that that excuses Giant Eagle, though.

This happened to me twice at the same Target. Once I caught it when I got home, once I didn’t (but it didn’t hurt me – just resulted in me dissolving a pill on my tongue that was meant to be swallowed. ARGH the taste!)

I really should have complained to the main office the first time, but when I did so after the second time, the response was immediate, thorough and kind of panicked – they swore they would do a training session at the store in question to address the problem, and then they called me back to tell me they’d done it. And when I went back to the pharmacy (because it’s convenient and I was satisfied with their response) a person I used to see there a lot (who always seemed kind of spaced out while ringing me up) was missing. No mixups since and I actually think service is faster now.

In short, always, always complain to the main office of a chain (which is more likely to smell a legal risk than the store manager) about a mixed-up prescription, if not for yourself then for the customers after you who may not be so vigilant about reading packaging.